SKIN-TO-SKIN CONTACT AS PAIN MANAGEMENT INTERVENTION FOR CLUSTERED PAINFUL PROCEDURES IN HEALTHY FULL-TERM NEONATES

Raouth R. Kostandy, PhD, MSN, RN, CKC Cleveland State University, School of Nursing

BACKGROUND Healthy full term neonates face many painful

procedures immediately after birth. Evidence exist that neonates perceive and

respond to pain (Anand, 2008; Simons & Tibboel, 2006).

Unrelieved procedural pain is related to detrimental physiologic and behavioral outcomes such as altered pain responses later in life (Grunau, Holsti & Peters, 2006; Hermann, 2006). Thus, pain need to be minimized.

BACKGROUND Skin-to-Skin Contact (SSC) is an effective non-

pharmacologic intervention for managing pain of a single procedure (Johnston et al., 2014). SSC relieves pain from one injection (Chermontet al., 2009; Kostandy et al., 2013) or heel sticks (Bulfone et al., 2011; Okan et al., 2010). skin to skin contact is now known as non-pharmacologic analgesic (Mooney-Leber & Brummelte, 2017).

The American Academy of Pediatrics (2007) has recommended SSC as a pain management strategy for term and preterm neonates.

PROBLEM AND PURPOSE Studies investigating repeated painful procedures can

be found, but, each study tested one painful procedure per day (Cignacco et al., 2012; Gitto et al., 2012). Investigations of clustered painful procedures during the postnatal period were not found.

There is a lack of information about SSC effects on clustered painful procedures.

The purpose of this study was to investigate the effects of SSC on physiologic and behavioral pain responses during and after clustered painful procedures in full-term neonates.

METHODS

Design: A pilot randomized controlled trial. Setting: Postnatal department of a tertiary

urban hospital. Sample: Sixteen mother-neonate dyads were

randomly assigned to either SSC group or control group.

METHODS CONT.

Inclusion Criteria:- gestational age 37-42

weeks- birth weight equal or more

than 2,500 grams- 5-minute Apgar score of at

least 7- judged clinically healthy- product of an uneventful

and spontaneous vaginal delivery or planned caesarean section, and

- mothers agree to provide SSC

Exclusion Criteria:- evidence of congenital

abnormalities or medical complications

- require oxygen administration or ventilatory support

METHODS CONT.

After obtaining IRB approvals a convenience sample of 16 mother-neonate dyads was recruited and maternal consents were obtained.

Neonates who met the study criteria were randomly assigned, using a pre-prepared sealed envelopes that was open in the mother’s presence in her room, to the intervention group (Skin-to-Skin, SSC) or control group (receive standard comfort measures, C).

METHODS CONT.

During the four study phases (Baseline, Heel stick, Injection, and Recovery) Heart Rate and Oxygen Saturation level were continuously recorded by Massimo Radical 7 pulse oximeter and downloaded into a laptop.

A video camera was set up to record the whole procedure.

From video taps, Behavioral State was assessed every 30 seconds by a research nurse trained to 0.95 reliability on the 12-state Anderson Behavioral State Scoring system (ABSS).

DATA ANALYSIS

Descriptive statistical tests were used to describe the sample.

The Wilcoxon Signed-rank test for testing differences in two groups when the data were cross-sectional was used. For longitudinal data analyses: (1) random effects logistic regression models for binary longitudinal behavioral states and (2) generalized estimating equations for Heart rate and Oxygen saturation were used.

RESULTS

There were no significant differences between groups on all demographic variables

Neonatal demographic characteristics:- 68.8% were female- 62.5% were white- 93.8% had a 5-minute Apgar score of 9- 56.3% were breastfed - All neonates had vitamin K injection

RESULTS CONT.

Maternal demographic characteristics: 55% had vaginal delivery 50% had epidural anesthesia Two mothers in each group reported that they

were smokers during this pregnancy one mother in the SSC group reported drug use

during this pregnancy

RESULTS CONT.

There were no significant differences between groups during Baseline in Heart rate, Oxygen saturation, and Behavioral state.

During Heel stick: Heart rate was marginally significantly higher in the SSC group (β= 9.16, 95% CI [-0.45, 18.77], p = 0.06). Oxygen saturation was significantly lower in the SSC group in comparison to the C group (β = -2.66, 95%CI = [-4.41, -0.92], p = 0.003). There were no significant differences in the Behavioral state between the two groups (β = 0.61, 95% CI = [-0.90, 2.12], p = 0.43).

RESULTS CONT.

During Injection: Heart rate was significantly higher in the SSC group than the C group(z = -2.63, p = 0.01). Oxygen saturation was also significantly lower in the SSC group (z = 2.28, p = 0.02). No significant differences were found in the Behavioral state (Z=1.07, p=0.28).

During Recovery period: Heart rate was significantly higher in the SSC group than the C group (β = 8.41, 95% CI [0.78, 16.03], p = 0.03). Oxygen saturation was significantly lower in the SSC group(β = -2.15, 95% CI = [-3.84, -0.46], p = 0.01). Control group neonates tended to have a higher behavioral state than SSC neonates (β = -0.78, 95% CI = [-1.71, 0.14], p = 0.10).

CONCLUSION

Heart rate data were similar to some previous studies. Heart rate tends to be higher during SSC. However, these differences were not clinically significant.

Generally oxygen saturation is higher during SSC which is conflicting with this study findings. In the current study, these differences were not clinically significant. However, there is scarce knowledge about Oxygen saturation during SSC in full term neonates.

CONCLUSION CONT.

Behavioral state data were similar to previous studies during recovery period. Only one previous study (Kostandy et al., 2013) used the ABSS in measuring behavioral state during one painful procedure.

Further studies with a larger sample size are needed to establish SSC role in the management of pain from clustered painful experiences.

NOTEWORTHY POINTS

At the time this study was conducted, the routine practice in the unit was to take all neonates to the nursery to perform these painful procedures.

All mother-neonate dyads completed the study protocol.

Only one nurse participated in this study. One neonate in the SSC group cried a lot during

the painful procedure, the nurse told the mother “oh boy, am I glad that you are holding him. I’m not sure what he would of done without you”

REFERENCES American Academy of Pediatrics (2007). New neonatal AAP pain management recommendations. Neonatal Network,

26(2),135. Anand, K.J.S. (2008). Analgesia for skin-breaking procedures in newborns and children: what works best? CMAJ,

179(1),11-12. Bulfone, G., Nazzi, E., & Tenore, A. (2011). Kangaroo Mother Care and conventional care: A review of the literature.

Professioni Infermieristiche, 64(2), 75-82. Chermont, A.G., Falcão, L.F., de Souza Silva, E.H., de Cássia Xavier Balda, R., Guinsburg, R. (2009). Skin-to-skin contact

and/or oral 25% dextrose for procedural pain relief for term newborn infants. Pediatrics, 124(6), e1101-e1107. Cignacco, E. L., Sellam, G., Stoffel, L., Gerull, R., Nelle, M., Anand, K. J., & Engberg, S. (2012). Oral sucrose and

"facilitated tucking" for repeated pain relief in preterms: a randomized controlled trial. Pediatrics, 129(2), 299-308. Gitto, E., Pellegrino, S., Manfrida, M., Aversa, S., Trimarchi, G., Barberi, I., & Reiter, R. J. (2012). Stress response and

procedural pain in the preterm newborn: the role of pharmacological and non-pharmacological treatments. European Journal of Pediatrics, 171(6), 927-933.

Grunau, R.V., Holsti, L., & Peters, J.W. (2006). Long-term consequences of pain in human neonates. Seminars Fetal Neonatal Med, 11(4), 268-275.

Hermann, C., Hohmeister, J., Demirakca, S., Zohsel, K., & Flor, H. (2006). Longterm alteration of pain sensitivity in school-aged children with early pain experiences. Pain,125, 278-285.

Johnston, C. C., Campbell-Yeo, M., Fernandes, A., Inglis, D., Streiner, D., & Zee, R. (2014). Skin-to-skin care for procedural pain in neonates. Cochrane Database of Systematic Reviews, Issue 7.

Kostandy, R.R., Anderson, G.C., & Good, M. (2013). Skin-to-Skin Contact Diminishes Pain From Hepatitis B Vaccine Injection in Healthy Full-Term Neonates. Neonatal Network, 32(4), 274-280.

Mooney-Leber, S.M. & Brummelte, S (2017). Neonatal pain and reduced maternal care: Early-life stressors interacting to impact brain and behavioral development. Neuroscience, 7(342),21-36.

Okan, F., Ozdil, A., Bulbul, A., Yapici, Z., & Nuhoglu, A. (2010). Analgesic effects of skin-to-skin contact and breastfeeding in procedural pain in healthy term neonates. Ann Trop Paediatr., 30(2),119-128.

Simons, S. & Tibboel, D. (2006). Pain perception development and maturation. Semin Fetal Neonatal Med., 11,227-231.